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}g, mw e •.«• , v,,,•9,. 9w - ' u .:�4t1 cof Health Service <br /> 1) ` statices'Control DlvlaloanB Novlag (wpalrocYs <br /> elks( >An«bPe:. onto Calltorala, <br /> t?p'• <br /> ., <br /> ~' S'. •r 1. ator's US EPA ID Na s , � l .y^Manliest. - age 1' - k <br /> UNIFORM`iHAZARDOU$ p 4th- I <br /> nformation k the ahaded areae <br /> WASTE MANIFEST A �d l7g9 1 ,7 r`gy g�m 5 of quired by Federal law. <br /> 3.,Peneralor's Name and Mailing Address �� .y/- �,. h��j�y)y ,rsG,V A.:plate Manifent Number <br /> * .y <br /> �..:{� "Tfv��T F "G •�rJ (gip G S:LC �� 7 <br /> B. glares/Genera _,,,�.t. Generator's Phone(2! ) Z�J LT`�v y•/TL�ji� / 1•' j1.. , 7 .:st -..S. Transporter 1 Company Name e. �^US E(PPA ID Number CState Tranep ./ UjY / , �j� D. Transporter's ..7. Transporter 2 Company Name 8. US EPA ID Number F State Transp <br /> m <br /> 0 F. Transponer's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G..State Facility's ID <br /> ! C OID191PPIR I? IjIjiJ <br /> U H. Facilffy's Phone <br /> 'Q .;A �t• �{v�r�2 « CA6 210101ei J77 f�OS�' 07:-05r/ <br /> �0 12. Containers 13. Total 14. .1.' <br /> W 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type Wt/Vol <br /> State <br /> E <br /> 3 N <br /> �N RE b. <br /> Stale <br /> T ." .. - EPA/Other <br /> N O <br /> V R C. <br /> State <br /> $ MAILED <br /> EPA/Other , <br /> F d' <' .State <br /> EPA/011ier,,—, , <br /> W <br /> AMitl«uI torte}Or-A4at0(lel Bd <br /> _ '� SIC /ie dIuCadea f«w t"Mated Above <br /> ¢ y�,�, �. �-a r�ty .ox'.c3 r?.����.. ktfY" } � w1}'�2�, ..,•9� ` ;s 3IV, <br /> m'Y t i <br /> +0^ <br /> Z <br /> o �"• »i.I:+w.- +n•-,un vc _sireS.fNwY se..N,�'r''4�*?•'s£.ie <br /> F 16. Special HandlNlg instructions and Ad -'onal inlomsation <br /> c Jc�� /? %�i�uE' f:� ,.� /• ro v:�9cT /S Au:7c� ,r/ }, <br /> J <br /> Q 18. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> national government regulations. <br /> If I am a large quantity generator.I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> ° to be economically practicable and that I have selected the practicable method of treatment,storage,or dig oral currently available to me which minimizes the <br /> present and future threat to human health and the environment;OR,if I am a small quantity generator.I h ve a good faith effort to minimize my waste <br /> ° generation and select the beat waste management method that is available to me and that 1 can afford. <br /> Z <br /> W Printed/Typed Name Signature Month Day Year <br /> R17. Transporter 1 Acknowledgement of Receipt of Materials <br /> = A Pmm d/Typed Name Signature Monf Dey <br /> 6 <br /> N AvNG 11�, ate.✓ l 3l <br /> P <br /> kill <br /> W O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> u <br /> ¢ T Printed/Typed Name - Signature Month Day Year <br /> U E <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted in Item 19. <br /> T <br /> y Printed/Typed Name Si namr _ <br /> 11"077-/ Y <br /> /"O� Q• ��7/� Month Day Year <br /> / <br /> / / G / lei7 <br /> HS 8022 A(1/88) Do Not Write Below This WjE <br /> PA 8700-22 ,QI_'d / <br /> ev.9-88)Previous editions are obsolete. s=/ <br /> T>E� HNES TBI; C..^r TO GENERATOR WITHIN 30 DAY, <br />